Analyst Reimbursement Managed Care

All the benefits and perks you need for you and your family:

• Benefits from Day One

• Career Development

• Whole Person Wellbeing Resources

• Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Job Location : Monday-Friday Remote

The role you'll contribute:

Responsible for ensuring the providers are loaded timely and accurately with Managed Care contracted payers. Responsible for evaluating professional fee contractual adjustments for accuracy in accordance with various payer contracts and/or federally mandated guidelines. This position supports the payment variance identification for the Physician Enterprise (PE) and works closely with practice office operations staff, Managed Care (MC) contracting, MC Credentialing and Enrollment and billing support teams to identify and recommend corrective action on payment variances and provider profiles with the payers.

The value you'll bring to the team:

• Submits the delegated and nondelegated credentialing reports once all credentialing and enrollment tasks have been completed by the MC Credentialing and Enrollment Teams.

• Responsible for confirming the providers submitted on the credentialing applications and the delegated and nondelegated credentialing reports are entered accurately and timely into the payer systems and directories.

• Enters effective date and provider number information received from the payers in Athena/Epic and MSOW Network Management thus releasing held claims and updating the status report for the practices.

• Reviews and resolves claim denials that are related to the credentialing and enrollment status of all AH employed providers.

• Responsible for identifying payment variances for professional fee commercial contracts and government payers. Reviews reports generated by Athena and/or PED to determine of the variances listed in the report, which are the true variances (under/overpayments) based on reimbursement guidelines from past billing/payer experience, payer websites, government updates, contracted fee schedules, etc.

• Liaisons with payer as directed by management to request provider profile updates, payment and/or within given guidelines, negotiates/approves discount.

• Closely works with MC contract administration and keeps open dialogue to ensure loaded contracts and provider specialties are accurate and updated as directed by management.

• Maintains a working knowledge of current rules and regulations of Commercial and Government programs.

• Reviews contractual adjustments to determine cause, aggregates and categorizes variance types in organized manner for management review.

• Serve as AdventHealth's subject matter resource for Commercial and Government payment variance identification, and education.

• Meets with PE and MC as directed by management to update current provider load, variance projects and specific payer issues.

• Analyzes data to provide payer reimbursement trends, payer load times and load accuracy for provider profiles.

• Coordinates with billing support teams as directed by management on identified payment variances and credentialing denials.

• Completes special projects as assigned by the reimbursement manager within the time frame requested.

Qualifications
The expertise and experiences you'll need to succeed:

KNOWLEDGE AND SKILLS REQUIRED:

• In depth knowledge of Commercial and Government program reimbursement rules and regulations

• Ability to research and interpret Commercial and Government payer rules and regulations

• Proficient in use of payment variance software

• Possess an understanding of variance reimbursement methodologies, auditing principles and their application to healthcare

• Strong computer software skills including Microsoft Office applications

• Ability to learn new technology applications used by Adventist Health System

• Strong analytical reasoning, critical thinking, judgment and problem solving skills in order to independently assess, interpret and address complex issues in a continually changing environment

• Excellent interpersonal skills

• Well organized and detail-oriented

• Ability to complete assigned tasks with limited supervision

Healthcare experience, Excel, Billing background

KNOWLEDGE AND SKILLS PREFERRED:

• System experience in identifying payment variances (Athena/Epic)

• Claim denial follow up with payers

EDUCATION AND EXPERIENCE REQUIRED:

• High school or equivalent degree

• Minimum of 3 years of relevant experience in healthcare reimbursement including Commercial and Government payers

EDUCATION AND EXPERIENCE PREFERRED:

• Bachelor's Degree in healthcare, business administration or related field

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